Ectopic Pregnancy

Introduction

Pregnancy that develops outside the uterus, very often in a fallopian tube. Ectopic pregnancy should be suspected in any woman of reproductive age with pelvic pain and / or metrorrhagia. There are many possible clinical presentations and these can mislead diagnosis towards appendicitis, intestinal obstruction, Salphingitis or abortion. The major risk of ectopic pregnancy is rupture, leading to intra - abdominal hemorrhage.

Clinical features and diagnosis

• Amenorrhea or irregular bleeding and spotting.
• Pelvic pain, usually adnexal.
• Adnexal mass by clinical examination or ultrasound.
• Failure of serum beta - hCG to double every 48 hours.
• No intrauterine pregnancy on transvaginal ultrasound with serum beta - hCG greater than 2000 milli - units / mL.

Management

If in doubt (negative urinary pregnancy test, no sign of rupture and stable hemodynamic conditions), hospitalize the patient for surveillance, if possible, in a surgical facility. Otherwise, refer immediately for emergency laparotomy.

Treatment

• Patients must be warned about the complications of an ectopic pregnancy and monitored closely.
• In a stable patient with normal liver and renal function tests, methotrexate (50 mg / m2) intramuscularly - given as single or multiple doses - is acceptable medical therapy for early ectopic pregnancy. Favorable criteria are that the pregnancy should be less than 3.5 cm in largest dimension and unruptured, with no active bleeding and no fetal heart tones.
• When a patient with an ectopic pregnancy is unstable or when surgical therapy is planned, the patient is hospitalized.
• Blood is typed and cross - matched. The goal is to diagnose and operate before there is frank rupture of the tube and intra-abdominal hemorrhage.
• The use of methotrexate in an unstable patient is absolutely contraindicated.
• Surgical treatment is definitive. In most patients, diagnostic laparoscopy is the initial surgical procedure performed.
• Depending on the size of the ectopic pregnancy and whether or not it has ruptured, salpingostomy with removal of the ectopic pregnancy or a partial or complete salpingectomy can usually be performed.
• Clinical conditions permitting, patency of the contralateral tube can be established by injection of indigo carmine into the uterine cavity and flow through the contralateral tube confirmed visually by the surgeon.
• Iron therapy for anemia may be necessary during convalescence.
• Rh (D) immune globulin (300 mcg) should be given to Rh negative patients.